HMTS Expedited Review Form

Attachment 3 - Health Message Testing System Expedited Review Form .docx

CDC and ATSDR Health Message Testing System

HMTS Expedited Review Form

OMB: 0920-0572

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Attachment 3: Health Message Testing System Expedited Review Form























Health Message Testing System Expedited Review Form


1. Title of Study: (Please append screener and questionnaire)


______________________________________________________________________________


2. Study Population: (Discuss study population and explain how they will be selected/recruited.)

______________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________


Respondent characteristics:

Number of subjects: _______________________

Number of males: _________________________

Number of females: _______________________

Age range: _______________________________

Racial/ethnic composition: __________________

Special group status: (e.g., risk group, health care providers, etc.)

Type of group/s: ________________________________

______________________________________________

Geographic location/s: _________________________________


3. Incentives: (If an incentive will be used, state what incentive will be offered and justify proposed incentives to be used in study.)

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


4. Study method: (Please check one below)

Central location intercept interview: _____

Telephone interview: _____ (CATI used: yes or no) _____

Individual in-depth interview (cognitive interview): _____

Focus group: _____

Online interview: _____

Other: (describe) _________________________________


5. Purpose of the overall communication effort into which this health message/s will fit: (Please provide 2-3 sentences below.)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6. Category of time sensitivity: (Please check one below)

Health emergency: _____

Time-limited congressional/administrative mandate: _____

Press coverage correction: _____

Time-limited audience access: _____

Ineffective existing materials due to historical event/social trends: _____

Trend tracking: _____


7. Describe nature of time sensitivity: (Please provide 2-3 sentences below.)

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________


8. Number of burden hours requested: __________


BURDEN HOURS


Category of Respondent

No. of Respondents

Participation Time

Burden









Totals





9. Are you using questions from the approved question bank? If yes, please list the item number(s) for questions used from the question bank.


Yes: _____

No: _____




*** Items Below to be completed by Office of Associate Director for Communication (OADC)***


1. Number of burden hours remaining in current year’s allocation: _______


2. OADC confirmation of time-sensitivity:

Yes: _____

No: _____

_____________________________________

Project Officer Signature


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleAttachment 3: Health Message Testing System Expedited Review Form
AuthorAngela Ryan
File Modified0000-00-00
File Created2021-01-25

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